Problems in Ingestion HARD

• The esophagus is a muscular tube that transports food from the mouth to the stomach.
• It is lined with mucus.
• It starts at the pharynx base and ends 4 cm below the diaphragm.
• Food and fluid transport relies on two sphincters:
  • Upper esophageal sphincter (hypopharyngeal).
  • Lower esophageal sphincter (gastroesophageal/cardiac).
• Incompetent lower esophageal sphincter causes gastric content reflux.
• The esophagus lacks a serosal layer, complicating surgery requiring suturing.

Esophageal Disorders

• Include motility disorders, hiatal hernias, diverticula, perforations, foreign bodies, chemical burns, GERD, Barrett esophagus, benign tumors, and carcinoma.
• Dysphagia is the most common symptom.
• It can range from food bolus sensation to acute odynophagia (pain on swallowing).
• Obstruction can occur anywhere along the esophagus.
• Patients can often pinpoint the location (upper, middle, or lower third).

Achalasia

• It involves absent or ineffective peristalsis in the distal esophagus.
• The esophageal sphincter fails to relax during swallowing.
• This results in a gradually increasing dilation of the esophagus in the upper chest due to narrowing above the stomach.
• It is rare, progresses slowly, and occurs most often in people between ages 20 and 40 and ages 60 and 70 years.

Achalasia: Clinical Manifestations

• Main symptom is dysphagia, specifically difficulty with solid foods.
• Patients feel food is stuck in the lower esophagus.
• Food is often regurgitated to relieve discomfort from esophageal distention.
• Noncardiac chest or epigastric pain.
• Pyrosis (heartburn) may or may not be associated with eating.
• Symptoms can mirror GERD.

Achalasia: Assessment & Diagnosis

• X-ray reveals esophageal dilation above the lower gastroesophageal sphincter narrowing (bird's beak deformity).
• Diagnostic tools: barium swallow, chest CT, endoscopy.
• High-resolution manometry confirms diagnosis (measures peristalsis, contraction amplitudes, and esophageal pressure).

Achalasia: Management

• Eat slowly and drink fluids during meals.
• Botulinum toxin injection inhibits smooth muscle contraction, but benefits fade, and fibrosis risk limits use to patients unsuitable for other treatments.
• Pneumatic dilation stretches the narrowed area.
  • High success rate, but usually requires two dilations.
  • Long-term results are variable.
  • Low risk of perforation.
  • Painful; requires sedation.
• Surgical options:
  • Esophagomyotomy (Heller myotomy) cuts esophageal muscle fibers.
  • Laparoscopic complete lower esophageal sphincter myotomy, with or without fundoplication (anti-reflux).
  • POEM (per-oral endoscopic myotomy) is a newer alternative.

Esophageal Spasm

• Three types: jackhammer esophagus, diffuse esophageal spasm (DES), and type III (spastic) achalasia.
• Jackhammer esophagus: Spasms occur on >20% of swallows, with very high amplitude, duration, and length. The term hypercontractile esophagus is also used.
• DES: Spasms are normal in amplitude but premature/uncoordinated, move quickly, and occur at various places in the esophagus at once.
• Type III achalasia: Lower esophageal sphincter obstruction with esophageal spasms.

Esophageal Spasm: Clinical Manifestations

• All forms: Dysphagia, pyrosis, regurgitation, and chest pain similar to coronary artery spasm.

Esophageal Spasm: Assessment & Diagnosis

• Esophageal manometry measures motility/pressure and is standard for irregular and high-amplitude spasms.

Esophageal Spasm: Management

• Smooth muscle relaxants (calcium channel blockers, nitrates) reduce contraction pressure/amplitude.
• Botulinum toxin for frail patients who cannot tolerate other interventions.
• PPIs if GERD symptoms are present.
• Small, frequent feedings and soft diet decrease esophageal pressure/irritation that causes spasms.
• Heller myotomy or POEM if conservative therapies fail.
• Surgical procedures addressing GERD may be beneficial.

Hiatal Hernia

• The opening in the diaphragm enlarges allowing the upper stomach to move into the thorax lower portion.
• More common in women than men.
• Two main types: sliding and paraesophageal.
• Sliding (Type I): Upper stomach and gastroesophageal junction are displaced upward and slide in and out of the thorax (90-95% of cases).
• Paraesophageal: Part or all of the stomach pushes through the diaphragm beside the esophagus.
  • Classified as types II, III, or IV (extent of herniation).
  • Type IV has the greatest herniation, with other intra-abdominal viscera present in the hernia sac.

Hiatal Hernia: Clinical Manifestations

• Sliding hernia: Pyrosis, regurgitation, dysphagia; many patients are asymptomatic.
• Vague intermittent epigastric pain or fullness after eating.
• Large hernias: Food intolerance, nausea, vomiting.
• Sliding hernias commonly associated with GERD.
• Hemorrhage, obstruction, volvulus, and strangulation can occur with any type, but are more common with paraesophageal hernias.

Hiatal Hernia: Assessment & Diagnosis

• Confirmed by x-ray studies.
• Other tests: barium swallow, EGD (esophagogastroduodenoscopy), esophageal manometry, or chest CT scan.

Hiatal Hernia: Management

• Frequent, small feedings that pass easily.
• Do not recline for 1 hour after eating.
• Elevate the head of the bed on 4- to 8-inch blocks.
• Surgical repair:
  • For symptomatic patients, primarily to relieve GERD.
  • Laparoscopic approach (Toupet or Nissen fundoplication) recommended.
  • Open transabdominal or transthoracic reserved for bleeding, dense adhesions, or injury to the spleen.

Hiatal Hernia: Post-Op Nursing

• Early post-operative dysphagia is common (up to 50%).
• Advance diet slowly from liquids to solids.
• Manage nausea and vomiting.
• Track nutritional intake and monitor weight.
• Monitor for belching, vomiting, gagging, abdominal distention, and epigastric chest pain (may indicate need for surgical revision).
• Surgical repair is often reserved for patients with more extreme cases that involve gastric outlet obstruction or suspected gastric strangulation, which may result in ischemia, necrosis, or perforation of the stomach.

Diverticulum

• Esophageal diverticulum: Outpouching of mucosa and submucosa through weak esophageal musculature.
• Occurs in three areas: pharyngoesophageal (upper), midesophageal (middle), or epiphrenic (lower).
• Zenker diverticulum (ZD): Most common type, located in the pharyngoesophageal area.
  • Caused by a dysfunctional sphincter that fails to open, leading to increased pressure.
  • Mucosa/submucosa herniate (pulsion diverticulum).
  • Usually seen in people older than 60 years of age.
• Midesophageal diverticula: Uncommon; symptoms less acute, surgery usually not required.
• Epiphrenic diverticula: Larger, in the lower esophagus above the diaphragm.
• Intramural diverticulosis: Numerous small diverticula associated with a stricture in the upper esophagus.

Diverticulum: Clinical Manifestations

• Pharyngoesophageal pulsion diverticulum:
  • Dysphagia.
  • Fullness in the neck.
  • Belching.
  • Regurgitation of undigested food.
  • Gurgling noises after eating.
  • Regurgitation when recumbent, coughing (tracheal irritation/aspiration).
  • Halitosis and sour taste (food decomposition in diverticulum).
• Other types: Dysphagia is the primary symptom, but less acute.

Diverticulum: Assessment & Diagnosis

• Barium swallow determines nature/location.
• Manometric studies for epiphrenic diverticula (rule out motor disorder).
• Esophagoscopy contraindicated (perforation risk and mediastinitis).
• Avoid blind NG tube insertion.

Diverticulum: Management

• ZD: Endoscopic septotomy (rigid/flexible) effectively treats ZD, with a recurrence rate of 11% to 30% of cases; POEM may be a better option as it is associated with a decreased risk of symptom recurrence.
• Surgery:
  • Care to avoid trauma to the common carotid artery and internal jugular veins.
  • Diverticulectomy and myotomy of the cricopharyngeal muscle to relieve spasticity.
• Post-op:
  • NG tube may be inserted.
  • Observe incision for leakage from the esophagus/fistula.
  • Food/fluids withheld until x-ray shows no leakage.
  • Progress diet from liquids as tolerated.
• Epiphrenic/midesophageal diverticula: Surgery only if symptoms are troublesome/worsening.
  • Treatment: Diverticulectomy and long myotomy.
• Intramural diverticula: Usually regress after esophageal stricture is dilated.

Gastroesophageal Reflux Disease (GERD)

• Backflow of gastric/duodenal contents into the esophagus.
• Causes troublesome symptoms and/or mucosal injury.
• Causes: Incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or motility disorder.
• Incidence increases with aging and is seen in patients with irritable bowel syndrome and obstructive airway disorder exacerbations (e.g., asthma, COPD, cystic fibrosis) peptic ulcer disease, and angina.
• Associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori.

GERD: Clinical Manifestations

• Hallmark: Pyrosis (heartburn), regurgitation.
• Other symptoms: Dyspepsia (indigestion), dysphagia or odynophagia, hypersalivation, and esophagitis.
• Complications: Dental erosion, pharynx/esophagus ulcerations, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications.

GERD: Assessment & Diagnostic Findings

• Patient history aids diagnosis.
• Diagnostic tests:
  • Ambulatory pH monitoring (gold standard): Transnasal catheter or endoscopic wireless capsule placement for ~24 hours.
  • Endoscopy or barium swallow: Evaluates esophageal mucosa damage and rules out strictures/hernias.

GERD: Management

• Patient education: Avoid situations that decrease lower esophageal sphincter pressure or irritate the esophagus.
• Lifestyle modifications: Tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet.
• Surgical intervention (if medical management fails):
  • Open or laparoscopic Nissen fundoplication: Wrapping a portion of the gastric fundus around the esophagus sphincter area.

Overview of the esophagus, a muscular tube transporting food to the stomach. Discusses its structure, function, and the role of sphincters. Also covers esophageal disorders like dysphagia, achalasia, and GERD, including symptoms and locations of obstruction.